Provider Demographics
NPI:1679789168
Name:MOCZYGEMBA, GERY WANE (DDS)
Entity Type:Individual
Prefix:
First Name:GERY
Middle Name:WANE
Last Name:MOCZYGEMBA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N KING ST STE 102
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4815
Mailing Address - Country:US
Mailing Address - Phone:830-303-4329
Mailing Address - Fax:
Practice Address - Street 1:515 N KING ST STE 102
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4815
Practice Address - Country:US
Practice Address - Phone:830-303-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice